Pharmacy Admin Manual - mc-rx.com · This Pharmacy Manual (“Manual”) is intended to serve as a guide with submitting claimsto assist to ProCare, as well as providing general terms,

ProCare Rx Pharmacy Manual: v4 Confidential & Proprietary

Page 1 of 24

PROCARE PHARMACY BENEFIT MANAGER, INC.

PHARMACY MANUAL

Copyright © ProCare Rx. All Rights Reserved 2020

ProCare Pharmacy Manual: 2019_v4 Confidential & Proprietary

Page 2 of 24

GENERAL INFORMATION: As a participating network pharmacy (“Pharmacy”), you have agreed to provide pharmaceutical services to persons covered by Plan Sponsors for whom ProCare Pharmacy Benefit Manager, Inc. (“ProCare”) provides pharmacy benefit management or pharmacy benefit administration services. This Pharmacy Manual (“Manual”) is intended to serve as a guide to assist with submitting claims to ProCare, as well as providing general terms, conditions, procedures and policies for adherence as a Participating Pharmacy (“Pharmacy”). This Manual is incorporated into your Participating Pharmacy Agreement along with any applicable amendments or addendums (collectively the “Agreement”). Pharmacies are responsible for reviewing and complying with all changes to the Manual. Failure to comply with any terms of the Agreement, which includes this Manual, as well as all other applicable documents, will be considered a breach of the Agreement. The information provided in this Manual is current as of the time of publication. This Manual will be updated as necessary and is subject to change without notice. The current version of this Manual is posted at https://pharmacy.procarerx.com. ProCare, at its sole discretion, may modify this Manual at any time. Changes to the Manual will be communicated via facsimile, email or posted online via https://pharmacy.procarerx.com. Please refer to the online claims adjudication system for the most current messaging and benefits information. For additional network participation requirements, please refer to your most recent Agreement. Any updates to your Pharmacy’s mailing/remit or physical address, telephone number, fax number, license number(s), DEA number or any other data must be submitted to the National Counsel for Prescription Drug Programs (NCPDP). PROCARE will not make manual updates to pharmacy demographic or licensure information unless it can be verified via NCPDP. PROCARE is not responsible for lost/late payments or delayed notifications due to incorrect pharmacy affiliation or mailing addresses. Please visit the ProCare’s Pharmacy Provider Portal (https://pharmacy.procarerx.com) to create an account to access important information, forms and notifications. ProCare appreciates your participation in our Pharmacy Networks and your role delivering quality Services to persons covered by our Plan Sponsors.

ProCare’s Pharmacy Manual is considered confidential and proprietary. Pharmacy agrees to not copy, distribute or share information included in this Manual, except as required for

business or contract purposes only.


Page 3 of 24

CONTACT INFORMATION:

PHARMACY HELP DESK SUPPORT:

Help Desk Hours of Operation: 24 hours a day, 7 days a week, 365 days a year.

Help Desk Phone: 800-699-3542

Prior Authorization (PA) Help Desk Phone: 866-965-3784

Help Desk Fax Number: 678-281-7586

NETWORK DEVELOPMENT DEPARTMENT:

Network Development Hours of Operation: Monday – Friday 8:00 am to 5:00 pm EST.

Phone Number: 800-277-2480

Fax Number: 678-207-5090

Email Address: [email protected]

Credentialing Department Email Address: [email protected]

Mailing Address: ProCare Pharmacy Benefit Manager, Inc. Attn: Network Development 1255 Professional Parkway Gainesville, GA 30507

OTHER IMPORTANT CONTACT INFORMATION:

Claims-related Issues or Questions: 800-699-3542

Member Eligibility: 800-699-3542

To report Fraud, Waste & Abuse (FWA): [email protected]

Pharmacy Dispute Resolution: [email protected]

Generic Pricing Appeals (MAC) Inquiries: [email protected]

Payment, Remit (835 Files) and EFT Questions: [email protected]

PROCARE PHARMACY WEBSITES:

ProCare Website: https://www.procarerx.com

ProCare HospiceCare Website: https://phc.procarerx.com

ProCare Pharmacy Provider Portal: https://pharmacy.procarerx.com


Page 4 of 24

PHARMACY RESPONSIBILITIES: The following terms are the Pharmacy’s basic responsibilities as a Participating Pharmacy (“Pharmacy”). Please refer to the Participating Pharmacy Agreement (“Agreement”) for additional information. In accordance with the Agreement, Pharmacy has agreed: 1. To comply and adhere to all provisions set forth herein this Manual. Failure to abide by the

provisions and/or terms set forth shall be considered a breach of the Agreement; 2. To provide professional pharmacy Services to Covered Persons, according to applicable local, state,

and federal laws and regulations, the Agreement, and the Manual;

3. To comply with all applicable state and federal privacy and security laws;

4. To verify, before dispensing Drug Products, whether an individual is a Covered Person by reviewing a valid Prescription Identification Card AND verifying the Covered Person’s eligibility on the date of service via on-line processing system (the “System”), OR by verifying eligibility by telephone in situations where on-line eligibility verification is unavailable;

5. To collect the applicable Co-payment, Co-insurance, and Deductible on each prescription as

specified by PROCARE’s online processing System, unless approved otherwise by PROCARE; 4. Pharmacy shall not waive the Co-payment, Co-insurance, or Deductible on part of a Covered Person

without the written consent of ProCare, or as specified below, or as required by applicable state or federal law, and that the Co-payment, Co-insurance or Deductible returned solely from the System is the maximum allowable amount to collect from the Covered Person, and no amount shall be collected above the amount sent back, unless approved by ProCare. Pharmacy shall follow the applicable rules and regulations as specified on discount coupons where applicable (refer to reverse side of coupon or the System);

5. To submit all Claims for Drug Products and Services on-line through the System for adjudication, in

either the NCPDP Version D.0 variable format or a more current and approved format, unless Pharmacy has received prior approval from ProCare. Usual and Customary (“U&C”) price must be submitted on each Claim. Manually submitted Claims may require Prior Authorization;

6. To maintain either a manual or electronic signature log or another form of signature verification

as allowed by state or federal law, at each dispensing location that contains the signature of each Covered Person or Representing Agent, fill date, prescription number and the date the Drug Product was delivered to Covered Person or Representing Agent so that pick up can be ascertained during any Pharmacy audit or review.

7. To complete annual Compliance and Fraud, Waste, and Abuse training in accordance with CMS

laws, rules, and regulations pertaining to 42 CFR § 423.504(b)(4)(vi)(c), where and when applicable, and as required by the Network and/or Plan Sponsors, in addition to frequently checking the OIG listing of excluded individuals and entities and removing any such employee from direct


Page 5 of 24

administration from applicable federal benefit Programs. In support of the above, audits may also be conducted by PROCARE, an applicable Payer, or other regulatory agency as outlined in 42 CFR § 422.504(e) and 42 CFR § 422.503(d)(2);

8. To maintain valid Pharmacy and Pharmacist DEA license(s) in order to dispense a narcotic or controlled substance Drug Product;

9. To comply with all provisions of e-prescribing standards as stated in the regulations 42 CFR §

423.160(b) when receiving or transmitting electronic prescriptions or prescription related information;

10. To use only e-prescribing to prescribe and dispense Services if the Pharmacy is a designated dispensing physician (“Physician Dispensary”);

11. To validate the prescribing physician’s NPI prior to submitting a Claim via the System; 12. To submit accurate Prescription Origin Codes, Patient Location Codes and other Coverage Codes

(where applicable);

13. To use the “Use as Directed” prescription instructions (SIG) only when an actual dispensing instruction is not available (please refer to the Audit section for further information).

14. To comply with grievance resolution for complaints filed by Covered Persons and/or Plan Sponsors

against Pharmacy, in accordance with local, state of federal laws or regulations.

NETWORK PARTICIPATION REQUIREMENTS & CREDENTIALING PROCESS ProCare has a formal credentialing process in which all pharmacies must complete for Network Participation. ProCare’s credentialing process is conducted in accordance with URAC and CMS standards. Pharmacies are required to comply with all credentialing and attestation policies set forth by ProCare and/or the Plan Sponsor. The credentialing process may vary depending on pharmacy type (i.e. independent, chain, PSAO) and service type (i.e. retail, mail service, compounding, LTC, physician dispensaries, etc.). ProCare monitors the licensure of its Pharmacies in accordance with ProCare policies and procedures, or as mandated by law. Failure to comply with licensure requirements and/or ProCare’s credentialing process may result in Pharmacy’s suspension or immediate termination. Any Pharmacy not eligible to participate in state or federal health care program(s) will not be allowed access into any of ProCare’s Networks. Pharmacies must comply with and promptly respond to requests for documentation in order to secure and maintain Network Participation status. Failure to respond may result in termination from the Networks. ProCare reserves the right to request credentialing documentation at any time during Pharmacy’s participation in ProCare’s Network(s).


Page 6 of 24

ProCare credentials Pharmacies prior to network acceptance. ProCare reserves the right, at its sole discretion, to determine eligibility of any Physician and Pharmacy of participation status within any of its Networks. Licensure: Pharmacy must submit a copy of a valid, current state pharmacy license in good-standing. Pharmacy must immediately notify ProCare, in writing, if the Pharmacy’s license has been cancelled, suspended, revoked or has any other action taken against it. The same requirement applies to Pharmacist in Charge (“PIC”) licensure. In the event the Pharmacy fails to notify ProCare or maintain the required licensure, ProCare may immediately terminate the Pharmacy from its Networks. The Pharmacy and PIC must hold a valid, current Drug Enforcement Administration (DEA) registration certificate and submit copies upon credentialing. Pharmacy must immediately notify ProCare, in writing, if the Pharmacy and PIC DEA registration has been cancelled, suspended, revoked or has any other action taken against it. In the event the Pharmacy fails to notify ProCare or maintain the required registration, ProCare may immediately terminate the Pharmacy from its Networks. Insurance: Pharmacy must maintain professional liability insurance at all times, in the amounts required by state or local guidelines. If there are no specified state or local guidelines, Pharmacy must maintain liability amounts of no less than $1 Million (occurrence) and $3 Million (aggregate) or in accordance with state law. If the Pharmacy’s liability insurance coverage lapses, Pharmacy agrees to notify ProCare immediately and take action to correct lapse in coverage. If Pharmacy loses liability insurance, Pharmacy shall be terminated from all ProCare Networks until coverage is reinstated and proof of insurance is provided. Mail Order: In addition to completing the Pharmacy Credentialing Form and providing the requested documentation, Mail order pharmacies must be licensed and provide copies of such licensure in their respective state and all states in which Drug Products are dispensed, mailed or shipped. Proof of licensure does not guarantee access in ProCare’s Mail Order Network. Access must be granted in writing by ProCare. Compounding Pharmacies: Pharmacies providing Compounded Drug Products will be required to submit additional documentation to validate proof of accreditation from a nationally recognized compounding accreditation agency, state certificate of inspection or proof, as required by state or federal law, as applicable. Pharmacies providing sterile compounding must meet current USP standards and provide proof from a nationally recognized compounding accreditation agency or provide state inspection documentation before participation with the Compounding Network will be granted. Compounding is Plan Sponsor specific and may or may not be a covered benefit. Refer to the System for coverage eligibility. Pharmacies may not circumvent the Plan Sponsor’s PA process in order to submit Compound Drug Claims. All compound claims are subject to review by the Plan Sponsor and/or ProCare.


Page 7 of 24

Pharmacy Credentialing Process: Pharmacy shall provide necessary documentation, licenses, and any other information as required by ProCare, or as applicable law permits. ProCare uses Primary and Secondary Source Verification during the Pharmacy Credentialing Process. The Credentialing Process includes, but not limited to, a review of the following for independent, non-affiliated pharmacies:

A completed, signed and dated Pharmacy Credentialing Form with a copy of the following documents:

State Pharmacy License

State Pharmacist In Charge (“PIC”) License

DEA License

Certificate of Liability Insurance (must not expire within 30 days of receipt)

Proof of Sterile Compounding from a nationally accredited compounding entity, if applicable

Any history of disciplinary action including loss, restriction or limitation on license

Malpractice claims history within the past ten (10) years

Fraud or abuse convictions within the past ten (10) years

Additional documentation/information as determined by ProCare

ProCare will verify all submitted documents and review the following:

Search of Office of Inspector General (“OIG”) Exclusions Database

Search of state department of licensure for pending/prior Pharmacy and PIC sanctions

Search of the U.S. Department of Justice Drug Enforcement Administration (DEA) Diversion Control Division website for verification of licensure status

The Chain/PSAO Credentialing Process includes, but not limited to, a review of the following documents:

Credentialing Form, signed and dated (required every two years)

Attestation Form, signed and dated (required annually)

Chain Contact Form (required annually)

Chain pharmacy roster including each pharmacy’s information

Pharmacy information must match NCPDP’s records for each pharmacy location


Page 8 of 24

ProCare will perform random quarterly credentialing audits of chain affiliated pharmacies by requesting the following documentation of the selected stores:

Copy of State Pharmacy License

Copy of State Pharmacist In Charge (“PIC”) License

Copy of Verification DEA License

Certificate of Liability Insurance (must not expire within 30 days of receipt)

Copy of proof of sterile compounding from a nationally recognized compounding accreditation entity, if applicable

Any history of disciplinary action including loss, restriction or limitation on license

Malpractice claims history within the past ten (10) years

Fraud or abuse convictions within the past ten (10) years

Additional documentation/information as determined by PROCARE

ProCare will verify all documents submitted and review the following for each selected pharmacy:

Search of Office of Inspector General (“OIG”) Exclusions Database

Search of state department of licensure for pending/prior Pharmacy and PIC sanctions

Search of the U.S. Department of Justice Drug Enforcement Administration (DEA) Diversion Control Division website for verification of licensure status

Telepharmacy: The practice of Telepharmacy is governed by the respective state’s definition of “practice of pharmacy” unless the governing state specifically provides an exception and in which the exception will govern. Pharmacies designated and acting as a Telepharmacy must be licensed in their respective state and each state where Services are performed. Each state’s law will dictate recordkeeping requirements for any Pharmacy designated and acting as a Telepharmacy. Electronic transaction data in lieu of physical pharmacy records may be accepted or in accordance with state law. Physicians: Physicians are required to comply with all credentialing and attestation policies set by ProCare and/or the Plan Sponsor. Physicians must provide necessary documentation, licenses and any other information required by ProCare, or as applicable law permits. Failure to comply may result in removal from ProCare’s Network(s). Physicians who are not eligible to participate in any state or federal health care Program(s) shall not provide Services for any Covered Person. Any Physician with sanctions against their state license(s), dispensary license (if applicable) and/or DEA license will be reviewed by the Credentialing Committee to determine eligibility into ProCare’s Network(s). ProCare reserves the right, at its sole discretion, to determine Physician eligibility to participate in ProCare’s Physician Network(s).


Page 9 of 24

OIG Validation: Pharmacy is required to have a process for checking and verifying the Office of Inspector General’s (“OIG”) List of Excluded Individuals/Entities (“LEIE”); System for Award Management (“SAM”) - Excluded Parties Listing System (“EPLS”) to confirm entity, employees and/or contractors have not been excluded from participation in federal programs. Verifications must be completed on a monthly basis. Proof of such validation may be requested at ProCare’s and/or Plan Sponsor’s discretion. Pharmacy agrees to report all employees/contractors found on the LEIE or EPLS exclusion list along with any Claims associated with the individual(s). In addition, Pharmacy agrees to notify PROCARE if Pharmacy is found to be listed on the exclusion list(s).

OIG: https://exclusions.oig.hhs.gov/

SAM: https://www.sam.gov/portal/SAM/#1

To report a Pharmacy or Pharmacist exclusion, please send an inquiry to Network Development team via email: [email protected]. Termination: Any Pharmacy terminated from ProCare Networks for reason(s) other than alleged FWA, must wait a minimum of three (3) years from termination date to apply for reconsideration for Network participation. Pharmacy will be required to meet ProCare’s credentialing requirements before Network Participation will be granted. Pharmacies terminated for FWA violations will not be allowed to reapply for Network Participation at any time. ProCare reserves the right, at its own discretion, to deny or suspend a Pharmacy’s Network Participation, with or without a thirty (30) day notice, should Pharmacy be found in material breach of one or more sections of this Manual or any Agreement. ProCare reserves the right, at its sole discretion, to determine eligibility of any Physician and Pharmacy of participation status within any ProCare Networks. Re-Credentialing: ProCare mandates that all Pharmacies must re-credential every other year (i.e. 2 year cycles), to ensure the continuation of Network compliance. Re-credentialing will be based on Pharmacy’s enrollment date (“Effective Date”) in ProCare’s Networks. For independent, non-affiliated Pharmacies, ProCare’s credentialing team will notify the Pharmacy in advance via the email address found in the Pharmacy’s NCPDP record. For chains/PSAOs and their affiliated pharmacies, ProCare will notify the point of contact designated by the chain of all re-credentialing requirements.

PAYER INFORMATION The listing below represents an example of the Plan Sponsors and respective Bin Identification Number (“BIN”), all of which are subject to change. For a specific copy of applicable payer sheets, please email [email protected].


Page 10 of 24

COMMERCIAL BINS

GENERAL PLAN NAME BIN PCN America’s Pharmacy Source 021981 APS

AVIA Partners (AVP) 018166 BLANK FILL

BMR (Broadreach Medical Resources)

018299 BLANK FILL

ConnectiveRx (CRx) 014310 BLANK FILL

CVS VA Hospital Group 018753 BLANK FILL

Health Plan of San Joaquin (HPSJ) 017043 BLANK FILL

Indiana MDAP 018364 INMDAP

Indiana HIAP 900020, 018364 INHIAP

Jai Medical Systems MCO 610084 CLAIMNE

Macaluso Compassionate Care Foundation (MCCF)

020271 BLANK FILL

Pivot Hub Services (Your Needs First)

020859 SEE CARD

ProCare EMP 014575 BLANK FILL

ProCare PBM East (BioScrip) 900020 CLAIMNE, CLAIMRX

ProCare PBM East (BioScrip) 018364 BLANK FILL

ProCare RX (PRX) 008266, 009430, 610489, 610601, 017812

SEE CARD

Safeway (SWY) 018159, 018166 BLANK FILL

TransAmerica (TAM) 015235 BLANK FILL

TrueRX Management Services 018224 BLANK FILL

Verity Solutions Group (VSG) 020313, 022344 BLANK FILL

Walmart Immunization Program 017647 SEE CARD

Wellpartner (WPI) 017515 BLANK FILL

340B Technologies, Inc. (BTI) 610719 BLANK FILL

CASH DISCOUNT CARD BINS

GENERAL PLAN NAME BIN PCN Agelity (AGL) 610198, 012965, 009265 BLANK FILL

Allegiance Rx 020826 BLANK FILL

AVIA Discount Card 018778 BLANK FILL

Managed Care Pharmacy (MPC) 013832 BLANK FILL

ProCare Discount Card 900014, 900020 SEE CARD

ProCare Discount Card 017614, 017670, 018372 SEE CARD

RX123, LLC 021056 BLANK FILL

SlashRx 610711 SEE CARD Note: As of the date of publication, the BIN list above is all-inclusive and is subject to change at any time.


Page 11 of 24

ON-LINE PROCESSING SYSTEM A claim form prepared in accordance with current National Council for Prescription Drug Programs (NCPDP) standards. The claim form, whether paper or electronic, must include all required fields necessary for adjudication (“Clean Claim”). If a Claim is determined, at the sole discretion of ProCare, to be discrepant, fraudulent or not authorized under applicable law or federal regulation, the claim will not be considered Clean and will be subject to recoupment by ProCare. Pharmacy is required to submit all Claims electronically to ProCare (see individual Payer sheets) via the system (“System”) within thirty (30) days of the date of fill. Pharmacies designated as Long Term Care shall submit Claims within ninety (90) days of the date of fill, or in accordance with state law. Claims from third party billing entities submitted on behalf of the Pharmacy will not be accepted and Pharmacy or its third party billing entity, is not entitled to any payment under this Agreement, unless prior written approval is given by ProCare. Notwithstanding the above, any Claim(s) granted such prior approval, shall be reimbursed to the Pharmacy directly per the contractual obligations between Pharmacy and ProCare. The System is available to accept electronic transactions 365 days per year. A transaction is any request and response, such as paid, reversed, rejected, duplicate, or adjusted, transmitted either through the System or manually keyed into the System. The Claim response governs, unless an overpayment is made. The System may, however, be unavailable during off-peak hours, such as overnight, for short periods of time, or due to scheduled system/file maintenance. Pharmacy has thirty (30) days from the original fill date to submit a Claim on-line (submission window may vary based on line of business and government regulations). Pharmacies designated as Long Term Care shall submit Claims within ninety (90) days of the date of fill, or in accordance with state law. If Pharmacy is not able to submit a Claim due to System unavailability, Pharmacy should hold the Claim for later on-line resubmission and/or contact ProCare’s Help Desk to verify eligibility and resubmit the Claim when the System becomes available. ProCare may charge a network transaction fee to Pharmacy of up to fifteen cents ($0.15) per on-line transaction submitted via the System. Out-of-network or Non-Preferred Pharmacies may incur a higher network transaction fee of up to fifty cents ($0.50). The transaction charge assists in the support of Pharmacy Help Desk operations and pharmacy financial (payment and reconciliation) services, in addition to Network compliance, communications, education, Geo-Access fees, directory management and notices, and is not Plan Sponsor specific. In the event of disruptive, excessive, or non-compliant Pharmacy behavior, higher transaction charges or penalty fees may be incurred.

MANUAL CLAIMS SUBMISSION Universal Claim Forms (“UCF”) will only be accepted for processing if absolutely necessary, with prior approval given by PrpCare and at a service fee of $1.00 per transaction, although some specific pre-authorized Claims may have this fee waived by ProCare in certain situations. Claims submitted with incomplete information will be rejected and may be charged an additional $1.00 per transaction handling to be deducted from a future Pharmacy remittance. Unauthorized manual Claims submitted by Pharmacy may be subject to a $3.00 handling fee. If approved, however, the following information will be required on all manual Claims:

Covered Person’s identification number Patient’s Name


Page 8 of 24

Patient’s Date of Birth

Patient’s Sex

Patient’s Relationship to Cardholder

Your Pharmacy NPI

Prescription number(s)

Appropriate DAW code (if necessary)

Date prescription was filled

Prescriber’s NPI number

Prior Authorization number (if required)

New or Refill indicator

Metric quantity dispensed

Days’ supply

11 digit NDC number

Requested Ingredient Cost

Requested Dispensing Fee

Copay Paid by Covered Person

Requested Tax (if applicable)

All approved UCFs should be submitted to:

ProCare Pharmacy Benefit Manager, Inc. ATTN: Claims Department 1267 Professional Parkway Gainesville, GA 30507

Claims must be received by ProCare from Pharmacy within 365 days of the date of fill for manual Claims to be entered into the System (this may vary for specific Plan Sponsor and plan eligibility).

SUBMITTING COMPOUNDED DRUG CLAIMS ProCare, at its sole discretion, may require Pharmacy to complete additional credentialing to process Claims for Compounded Drug Claims. Pharmacy will be required to meet all credentialing standards as established by ProCare to include, but not limited to; Pharmacy Compounding Accreditation Board (PCAB) accreditation, proof of federal and/or state registration of sterile compounding, state/federal inspection reports, compliance with Stark and Anti-Kickback laws, compliance review to include business operations/practices and on-site review of stability and sterility. Failure to remain maintain compliance with the requirements may result in removal from applicable Networks or termination of the Agreement. Any evidence of unsafe compounding practices reported to the State Board of Pharmacy, Food and Drug Administration (FDA) or applicable regulatory agency will warrant removal from ProCare’s compounding Network and/or termination of the Pharmacy Agreement, at ProCare’s sole discretion. Documented unsafe compounding practices could lead to Claim recoupments or non-payment of Compounded Drug Claims. Pharmacy acknowledges and agrees that the approval of Compounded Drug Claims is based on Plan Sponsor approval and may be subject to quantity limits, dollar thresholds and/or Prior Authorization (“P/A”). Pharmacy understands submitting the level of effort (“LOE”) code may not result in a change in the reimbursement of the Compounded Drug Claim. When approved by Plan Sponsor, LOE code reimbursement may differ by Plan Sponsor. A Compounded Drug Claim contains a Drug Product which is weighed or measured by a licensed pharmacist who combines, mixes, and/or alters ingredients to create a medication for a Covered Person for which a commercial Drug Product is not available. This excludes reconstitution and/or dilution of a Drug Product according to manufacturer guidelines. Sweeteners and flavorings are also excluded.

ProCare Rx Pharmacy Manual: 2019_v4 Confidential & Proprietary

Page 9 of 27

All Compound Drug Claims must be submitted through the System using the compounding code indicator “2” in NCPDP field .0 406-D6 with each ingredient NDC, cost and quantity used. If LOE code is approved for use, the appropriate LOE code must be submitted in field 474-8E of the NCPDP D.0 claim format. Pharmacy agrees to the following:

To follow the PA process as required by Plan Sponsor and ProCare for all Compound Drug Claims.

Not to engage in acts of resubmitting a Compound Drug Claim multiple times with the same quantity and different U&C until the Claim is paid to circumvent the P/A process, also known as price rolling.

Not to bill a different NDC or dosage than what was used.

Not attempt to obtain higher reimbursement by replacing ingredients (unless prescriber authorizes or a new Prescription with different ingredients is received).

Not to increase dispensing fees, ingredient cost, quantities and/or day’s supply amounts.

Not to submit a Compounded Drug Claim for a drug that is equivalent to a commercially available drug (such Claims are subject to full recovery in an audit).

Not to submit a Compounded Drug Claim for a single NDC pre-made compound or compound kit.

Not to submit reconstituted preparations as compound drugs (i.e. mixing water or saline with other Federal Legend Drugs prior to dispensing).

Not to submit prescriptions sub-divided into unit dose(s) as compound drugs.

Not to submit injectable drugs drawn into syringes for administration as compound drugs.

Not to charge for ancillary supplies, such as flavorings/sweeteners, equipment depreciation and/or labor under the terms of the Agreement.

To submit all Compounded Drug Claims via the System using compounding code indicator “2” and use the appropriate Level of Effort (LOE) code.

The following acts may result in termination from ProCare’s Networks; (1) waiving the Covered Person’s Co-payment/Co-insurance amount, (2) charging the Covered Person a higher Co-pay/Co-insurance amount, (3) charging for non-covered ingredients, (4) refusing to fill due to reimbursement, (5) engaging in acts of questionable billing practices, (6) using in appropriate LOE code.

Pharmacy is expected to observe all applicable state and federal laws pertaining to U.S. Pharmacopoeia (“USP”) Chapter Guidelines, Federal Drug Administration (FDA) communications and professional standards when dispensing Compound Drug Products. If for any reason, evidence of unsafe/unprofessional compounding is found, said evidence will be reported to the FDA and applicable State Board of Pharmacy, which may result in termination of the Agreement.


Page 10 of 27

GENERAL CLAIMS, PRICING, AND PAYMENT INFORMATION Claims submitted by Pharmacy through the System will be reimbursed at the lesser of the Pharmacy’s U&C charge or cash price; submitted ingredient cost; submitted total amount due; maximum allowable cost (“MAC”); or AWP minus the applicable Network rate, plus the applicable dispensing fee (including any applicable state or local tax). The reimbursement rates may vary by Plan Sponsors. Tax will be calculated based on available and approved state or local tax on prescription drugs when submitted by Pharmacy. ProCare shall utilize Medi-Span, First Databank, or any other such nationally accepted database as its pricing source. AWP pricing for Drug Products shall be calculated using the current AWP benchmark and methodology on aggregate, where applicable, at an individual Plan Sponsor level. Plan Sponsor participation may vary in the implementation, application, and utilization of the post AWP methodology at point of sale via the System. Should AWP become obsolete or market conditions warrant a change in pricing methods, other nationally recognized referenced based pricing sources, such as WAC based pricing or suggested wholesale price may be implemented and utilized. Upon the return of a paid Claim response to the Pharmacy via the System, Pharmacy has agreed to accept terms, rates, and participation. Pharmacy may not bill a Covered Person in excess of the applicable Co-payment amount returned on a paid Claim via the System, unless allowed by state and/or federal law. The Agreement does not exclude or guarantee access into all Networks, and Plan Sponsors may utilize alternative, limited or restricted Networks. ProCare’s Pharmacy Network and reimbursement includes, but is not limited to, commercial, Medicare Part D, Medicaid, long term care, home infusion, hospice, consumer operated and orientated plan Programs, worker’s compensation, discount cards, cash cards, coupon voucher, reward and restricted Programs, vaccinations (including professional allowance), specialty, mail order, health care cooperatives, or other custom Plan Sponsor Networks. Pharmacy acknowledges and agrees the acceptance of a successfully adjudicated Claim means; (1) Pharmacy agrees to participation in applicable Network(s), (2) Pharmacy agrees to accept rates and reimbursement of Claim, for applicable Network(s). In the event of a conflict between the Agreement, addenda, exhibits, amendments, Manual or the System adjudication response, The System response shall govern, unless an overpayment error occurs. ProCare shall recoup overpayments on behalf of the Plan Sponsor, or in accordance with state law. Pharmacy agrees and understands contacting a Plan Sponsor who utilizes ProCare’s Networks directly for any pricing disputes or Claim processing issues, unless permitted by ProCare in writing, is strictly prohibited. Furthermore, Pharmacy also agrees and understands ProCare submits payments to the Pharmacy for approved Claims and Pharmacy will not pursue a Plan Sponsor for any additional financial payments or incentives. Such violation is considered prohibited and may be subject to financial penalties of one thousand dollars ($1,000) per incident/per day and Pharmacy’s termination from the Network(s). If Pharmacy is affiliated with a third party contracting/purchasing group, Pharmacy is subject to all terms and conditions of this Manual and the third party’s agreement, addenda, amendments and exhibits. If affiliated Pharmacy is found to be in breach of any terms or conditions of the said agreement, addenda, amendments, exhibits and/or Manual, Pharmacy may be terminated from all ProCare Networks at ProCare’s sole discretion. ProCare processes Pharmacy payments twice per month, or sooner, as required by state or federal law and/or requirements. Financial cycles may be changed or altered as a result of a contractual obligation to


Page 11 of 27

a Plan Sponsor, or in accordance with state Prompt Pay regulations or federal laws. In these situations, ProCare will notify Pharmacy in the next subsequent check issuance of any future financial cycle modifications, if applicable.

CLAIM ADJUSTMENTS AND REVERSALS Pharmacy may adjust a Claim when it has been submitted incorrectly, or if the Covered Person wishes a switch to Brand or Generic Drug dispensing. To request a paid Claim be adjusted, Pharmacy should submit the Claim on-line (reversal and re-submission) or, under limited circumstances, submit a manual Claim form indicating “REVERSAL” or “ADJUSTMENT”. For on-line Claims, all requests for Claim adjustments must be received and processed by ProCare within thirty (30) days of the fill date, or as required by applicable federal or state law. Pharmacies designated as Long Term Care shall submit Claims within ninety (90) days of the date of fill, or in accordance with state law. For manual Claims (when allowed), all requests for Claim adjustments must be received and processed by ProCare within ninety (90) days of the date of fill to be eligible for an adjustment. However, ProCare may, at its own discretion, approve submission outside of the ninety (90) day window. Pharmacy agrees to reverse Claims within fourteen (14) days of original submission for all medications not picked up by a Covered Person. Failure to reverse Claims not picked up by a Covered Person are subject to Claim reversal plus a five hundred dollar ($500.00) penalty per Claim, if found via Pharmacy audit.

GENERAL CLAIM DISPUTES In the event a Pharmacy wishes to dispute a Claim due to an alleged discrepancy, error or noncompliance with regard to terms of the Pharmacy Agreement, Pharmacy must notify ProCare in writing within sixty (60) days of the date of fill, or in accordance with the Agreement or state or federal laws, if applicable. The Claim dispute notification must include Pharmacy’s NCPDP or NPI number, Covered Person’s ID number, prescription number, date of fill, Claim reference number and detailed information stating the reason for the dispute. ProCare shall have thirty (30) business days to respond to the notification provided all documentation/information is provided from the Pharmacy. In the event ProCare requests additional documentation/information, the Pharmacy must comply in a timely manner to provide ProCare the requested information. Once the additional requested information is received from the Pharmacy, ProCare has thirty (30) business days to research and respond to the Pharmacy’s appeal. Claim dispute notifications should be emailed to: [email protected].

ProCare’s appeals process provides three (3) levels of review:

1. First Level Appeal – ProCare’s Clinical Team 2. Second Level Appeal – ProCare’s Clinical Team [2] 3. Third (and final) Level Appeal – a contracted external review organization (“ERO”)

Expedited appeals are determined and verbal notification to the member and prescriber is provided within 72 hours from receipt of request and written notification within three (3) calendar days of request.

mailto:[email protected]


Page 12 of 27

Non-Expedited (standard) appeals are responded to within 30 calendar days of request. This policy is available to members and prescribers upon request.

Procedure

If the initial Coverage Decision is denied and First Level Appeals are not delegated to ProCare, the notification will refer the member to their respective health plan.

The First Level Appeals process shall be as follows:

1. When the appeal is received in writing or telephonically, the request shall be forwarded to ProCare's Clinical Team for review.

2. ProCare's Clinical Team may obtain additional information from the treating

prescriber and or claim information, and other such clinical materials including FDA approved package inserts, industry clinical journals and other information that may be relevant to making an impartial decision.

3. ProCare's Clinical Team shall review the appeal and document in writing their

decision.

4. If the decision is to deny, the Member and Prescriber are notified of the denial in writing, along with the process to file a secondary appeal if the member/prescriber does not agree with the findings. If secondary appeals are not delegated by the client to ProCare, the appeal letter will refer the member to their health plan.

If the appeal is overturned, the member and prescriber are notified in writing. ProCare’s Clinical Team will add rule into claims processing system allowing the claim to pay.

The Second Level Appeals process shall be as follows:

1. The case, including all documentation in the previous steps, shall be submitted to

ProCare's clinical pharmacist.

2. ProCare's Clinical Team [2] may obtain additional information from the treating prescriber and or claim information, and other such clinical materials including FDA approved package inserts, industry clinical journals and other information that may be relevant to making an impartial decision.

3. A review shall be performed by ProCare's clinical pharmacist, and their decision is documented in writing. 4. If the First Level Appeal is overturned, the member and prescriber are notified in writing.


Page 13 of 27

5. If the decision is to uphold the original denial, the Member and Prescriber are notified of the denial in writing, along with the process to file a final appeal if the member/prescriber does not agree with the findings.

The Third (and final) Level Appeals process shall be as follows:

1. The case, including all documentation in the previous steps, will be submitted to

a contracted external independent review company for review.

2. A review shall be performed by the contracted external independent review company, and their final decision is documented in writing.

3. Client shall be notified in a summary document of the final decision by the contracted external independent review company.

4. In accordance with the arrangement between ProCare and the client, the Member shall be notified of the final decision of the contracted external independent review company.

5. For health plan clients and other approved entities that may accept PHI, the documentation provided by ProCare may include patient specific information.

Appeal documentation is managed electronically. The documentation of appeals includes the following:

• Consumer demographics • Correspondence from the consumer/prescriber • Dates [open, reviewed and closed] • Name and credentials of clinical peer • Clinical review criteria if a non-certification is determined.

Appeal reports are submitted to the QC on a quarterly basis. NOTE: All appeals are reviewed by Pharmacists or Physicians as permitted by state appeal laws, who were not involved in the original denial decision. Neither the individual who made the original non-certification, nor the subordinate of such individual is involved in the appeal.

ProCare is committed to using good clinical practice guidelines, and uses information derived from a review of currently available clinical information, including clinical outcome studies in the peer-reviewed published literature, regulatory status of the procedure, evidence-based guidelines of public health research agencies, evidenced-based guidelines, views of practitioners practicing in relevant clinical areas, and other relevant factors. ProCare makes no representation and accepts no liability with respect to the content of any external information cited or relied upon in establishing the clinical practice guidelines. The description, background and positions reflected in the clinical practice guidelines, including any reference to a specific provider, product, process or service by name or trademark, manufacturer, constitutes ProCare’s opinion and are


Page 14 of 27

made without intent to defame. ProCare further makes no representation that these opinions are endorsed by any healthcare provider or health care provider society, and reserves the right to revise the clinical practice guidelines as clinical information changes.

The conclusion that a particular drug or service is acceptable does not constitute a representation or warranty that this drug service is covered for a member’s benefit plan. The member’s benefit plan determines coverage.

GENERIC DRUG (MAC) APPEALS

ProCare’s MAC list(s) are considered proprietary and confidential and are updated by ProCare, at its sole discretion. ProCare utilizes multiple sources to ensure the MAC list(s) reflect market pricing and Generic Drug Product availability. ProCare is committed to reviewing fully completed and submitted MAC appeals in a timely manner, or in accordance with state guidelines. Requirements for MAC appeals may be found on the Generic Pricing Appeal Form located on the Pharmacy Portal. Pharmacy agrees not to delay, withhold or impact Covered Person access to Services in the event a MAC appeal is generated by Pharmacy. In addition, Pharmacy shall not involve the Covered Person or Covered Person’s Plan Sponsor of such reimbursement disputes. An independent pharmacy holding a direct Agreement with ProCare may submit a MAC appeal directly to ProCare via [email protected]. An independent Pharmacy under a third party affiliation (“PSAO”) or chain agreement must direct all MAC inquiries to their affiliation for proper handling, unless otherwise indicated by ProCare. A MAC appeal sent to ProCare by an affiliated independent Pharmacy will not be reviewed unless prior permission has been granted solely by ProCare. It is the expectation of ProCare that all MAC appeals sent by a chain affiliation are fully reviewed and screened prior to submitting to ProCare for review. Appeals will not be reviewed for Claims reimbursed at U&C, submitted ingredient cost, claims reimbursed at AWP discounts or Brand Drug Claims. Duplicate Claims will not be reviewed and are limited to one (1) individual Claim reference number per appeal. Appeals submitted without the required supporting documentation, such as pharmacy name, pharmacy NCPDP/NPI, BIN, prescription number, fill date, Drug Product NDC and acquisition cost shall be considered incomplete and will not be reviewed until all information is received. All completed appeals must be emailed to [email protected] within sixty (60) days of actual Claim fill date, or per federal and state guidelines. Reviews and final determination of accepted MAC appeals shall average five (5) to seven (7) business days, or in accordance with state law. Where applicable, upon final decision and determination of an accepted MAC appeal submission, ProCare will provide Pharmacy a reason for denial of the MAC appeal. If Pharmacy is located in a state that requires a different time period to submit/resolve MAC appeals, ProCare will abide by state requirements. Upon written request, and as required by law, ProCare will make MAC lists available to Pharmacy. Pharmacy agrees ProCare’s MAC list is considered confidential and proprietary and may not be distributed or discussed.


Page 15 of 27

PRESCRIPTION IDENTIFICATION CARD The Covered Person’s eligibility must be verified through the System or by contacting the specific telephone number listed on the back of the applicable Prescription Identification (ID) Card. Covered Persons are instructed to provide their ID Card(s) when obtaining a Drug Product and/or Service from a participating Pharmacy. Covered Persons in nursing homes, Long Term Care (LTC) facilities, and hospices are not required to present ID cards. ProCare’s Help Desk phone number is found either by referencing the back of the ID card or by referring the on-line Claims response, when applicable. Please note: for same-sex twins, key in first names and date of birth.

Sample ID Card:

COORDINATION OF BENEFITS (“COB”) Coordination of Benefits (COB) with a Covered Person’s other coverage may vary between Plan Sponsors and may or may not be allowed. Please refer to System or applicable payer sheet for proper direction and facilitation of all COB Claim submissions after validation of all other information is initially made with the Covered Person.

REMITTANCE ADVICES

ProCare will provide Pharmacy with remittances (either paper or electronic) for Claims processed, where applicable, within their respective payment cycle. Additional fees may apply for remittance recreations or additional services where original remittances have already been delivered to Pharmacy or its authorized agent, without error, as confirmed by ProCare. The below outlines the applicable fees.

Type Fee*

Paper and Electronic remittance recreation $25 (per pharmacy, per cycle)

Stop payment on check $35 per check

Remittance research or documentation request $25 per half-hour (minimum 1 half-hour)

*Fees shall be charged and withheld through future billing cycle withholds to Pharmacy or its authorized agent.

PLAN SPONSOR NAME HERE PLAN SPONSOR INFORMATION HERE

BIN #: 009430 GROUP #: 123456789 ID: 123456789 NAME: SAMPLE MEMBER PHARMACY HELP DESK: (800) 699-3542

Member: Drugs that are covered by your plan may be filled by participating Pharmacies per your plan requirements. This card is for identification purposes only, and you may be required to provide additional ID at the time your prescription is filled. Presentation of this card does not guarantee eligibility. Unauthorized or fraudulent use of this card is punishable by law and PROCARE reserves the right to revoke this ID card at any time for cause. Pharmacy: PROCARE is not responsible for payment of Claims to a non-participating pharmacy. For Prior Authorizations, please call: 1-800-211-8592.

PROCARE 1267 Professional Parkway

Gainesville, GA 30507 Pharmacy Help Desk 1-800-699-3542


Page 16 of 27

CLINICAL P & T COMMITTEE ProCare’s P&T Committee will review the use and therapeutic effects of several classes of drug products within the same therapeutic class to identify preferred agents based on safety, efficacy, effectiveness, and dramatic cost variances. However, cost will not be a primary consideration in determining the safety and/or efficacy of a drug.

In general, the procedure for therapeutic class review will be as shown below. ProCare’s P&T Committee will not specifically be bound by the procedure below in determining which therapeutic classes to review, or under what time schedule, if additional factors such as new drugs entering the market, loss of patent, or FDA warnings occur.

1. The P&T Committee will approve inclusion or exclusion of individual therapeutic classes in

the printed formulary on an annual or as needed basis.

2. Each of the top twenty (20) therapeutic classes, which are determined by utilization and general medical practice by the acting P&T Committee chairman, will be reviewed annually at ProCare's annual onsite P&T Committee meeting. Annual reviews will always be performed on the following primary therapeutic classes, regardless of utilization or general medical practice priority:

Diabetes

Hypertension (Cardiovascular)

High Cholesterol

Blood Modifiers

Rheumatoid Arthritis

Multiple Sclerosis

Respiratory Agents

Oncology

3. Based on the outcomes of the therapeutic class reviews and given current good medical practice, the P&T Committee will recommend the development of new drug use criteria, new treatment guidelines, or changes to the formulary, including change in tier placement, implementation of any prior authorization requirements, and/or implementation of step edit protocols or prescription quantity limits.

4. Formulary therapeutic categories and classes may be changed based on the guidance of the P&T Committee, which will include the addition of new drug entities and new therapeutic uses, or the reclassification or further breakdown of a specific therapeutic category or class listed to provide better guidance to practitioners and prescribers.

DRUG FORMULARY ProCare may manage Drug Formularies for payers of health care; such as, employer groups, universities, regional HMO’s and other plan types, through its on-line Claims adjudication system (the System). ProCare’s Pharmacy and Therapeutics (“P&T”) committee meets at regular intervals to review which Drug Products are appropriate for inclusion in the Drug Formulary, based primarily on clinical efficacy and


Page 17 of 27

secondarily on payer cost. If a submitted Claim is non-compliant with the Drug Formulary and the Plan Sponsor has opted for a closed Formulary benefit, the Claim will reject and an on-line message will be returned to the Pharmacy indicating the preferred Drug Product. For selective Formularies, the Covered Person’s co-payment may be higher, again with an indication of the preferred Drug Product. Current, printed Drug Formularies are available upon request by contacting the phone number listed on the back of the Covered Person’s ID Card.

ANCILLARY CHARGES Ancillary Charges are charges incurred above and beyond the standard Co-payment/Co-insurance charge (i.e. deductible(s) and/or DAW penalties) and may vary by Plan Sponsor. If any Ancillary Charges have been applied to the Covered Person, Plan Sponsor, or the Pharmacy, such charges will be noted via the System.

340(B) PROGRAM

In the event the Pharmacy is contracted, owned or operated by an eligible 340(B) participating entity allowing the purchase of Drug Products at a reduced cost under the Public Health Service Act, Section 340(B) program, Pharmacy shall immediately inform ProCare with written notice of eligibility. Failure to provide such documentation shall constitute a material breach of the Agreement.

ORIGIN CODE REQUIREMENTS

Prescriptions, including refills must contain an Origin Code value according to the chart below on all Claims submitted. Claims without a value will be rejected/denied at the point of sale.

VALUE VALUE TYPE

00 Original dispensing — the first dispensing

01-99 Refill number — number of the replenishment

ALL NEW PRESCRIPTIONS MUST CONTAIN ONE OF THE FOLLOWING NUMERIC VALUES:

1 Written

2 Telephone

3 Electronic

4 Fax

5 Used when a new prescription number needs to be created from an existing valid prescription. (i.e.; traditional/intra-chain transfers, file buys and system/software upgrades. Also appropriate to use for over-the-counter, Plan B, pharmacist’s authority to prescribe, etc.

DISPENSE AS WRITTEN (DAW) ProCare utilizes all DAW/Product Selection Codes as specified by NCPDP. The matrix below serves only as a guide and may be used when dispensing a multi-source Brand Drug Product where an Orange Book ‘A’ rated Generic Drug Product is available. Additionally, these values are Plan Sponsor benefit specific and may vary by Plan Sponsor. Valid DAW values are as follows.


Page 18 of 27

DISPENSE AS WRITTEN (DAW) PAYMENT MATRIX

DAW REASON ACTION WHO PAYS PENALTY*

CO-PAY BASIS

0 No Product Indicator Pay Pharmacy Brand

1 Physician Requested Product Pay None Brand

2 Covered Person Requested Product

Pay Covered Person

Brand

3 Pharmacist Requested Product

Pay Pharmacy Brand

4 Generic Drug Not in Stock Pay Pharmacy Brand

5 Brand Drug Used as Generic Pay Pharmacy Brand

6 Override Pay Pharmacy Brand

7 Brand Mandated by State Law Pay Pharmacy Brand

8 Generic Not in Marketplace Pay Pharmacy Brand

9 Other Reject Pharmacy Brand

*Offered as a general guideline. May vary between Plan Sponsors. Penalty values may also vary per Plan. Invalid or incorrect DAW submissions may result in inaccurate reimbursement.

DRUG PRODUCT QUANTITY LIMITS

Maximum Days’ Supply Parameters *

DISPENSORY LIMITATIONS

RETAIL: 30-34 Days’ Supply. Refills Limited by State Law.

MAIL SERVICE: 90 Days’ Supply for Maintenance Drugs. Refills Limited by State Law.

Refill Parameters *

ISSUE LIMITATIONS

PRESCRIPTION UTILIZATION REQUIRED BEFORE REFILL ALLOWED

RETAIL: 80% MAIL SERVICE: 85%

* The examples above are the most commonly utilized at ProCare; however, both the maximum days’ supply and refill parameters vary by Plan Sponsor and benefit.

SIGNATURE LOGS Pharmacy shall maintain, at each dispensing location, either a manual or electronic signature log, or other electronic proof of pickup. The log must contain the Covered Person’s name, date of fill, prescription number and the date the Drug Product or Service is received by Covered Person or Representing Agent. Home Delivery Logs: If Pharmacy delivers a Drug Product to a home or business address, the log must include; Covered Person’s name, address of delivery, prescription number, date of fill, signature of Covered Person or Representing Agent, date of delivery, time of delivery and delivery person’s signature, or in accordance with state law.


Page 19 of 27

Mail Order Pharmacy Logs: For pharmacies licensed and authorized by ProCare to act as a mail order pharmacy, shipping logs must include; Covered Person’s full name, Covered Person’s mailing address, prescription number, date prescription filled, date prescription mailed and delivery confirmation of each prescription, or in accordance with state law. Failure to comply with signature log requirements may result in full recoupment of Drug Product or Service reimbursement and/or penalty. Signature Logs must be maintained for all Claims submitted through the System.

PRIOR AUTHORIZATION AND PROCEDURES Prior Authorizations (“PA’s”) may be required for eligibility, age restriction overrides, fast refill, vacation supply, compounds, maximum days’ supply, and several other drug categories, as well as, certain prescriptions filled at retail with a drug cost greater than five hundred dollars ($500.00) or any prescription filled at mail service, when allowed, with a drug cost greater than one thousand dollars ($1,000.00). To obtain a PA number, the Pharmacy must contact the pharmacy support number listed on the back of the Covered Peron’s ID card. PA numbers are specific to the Covered Person’s ID number, prescription number, 11-digit NDC, fill date, and Pharmacy NCPDP/NPI. PA numbers may only be used once and are not applicable to any impending refills of the same prescription. Standard timeframe Coverage Determinations (including medical necessities, plan benefit reviews, appeals and reconsiderations) 1. The maximum timeframe from initial fax to final determination will not exceed fourteen (14) calendar days for initial determinations, and thirty (30) calendar days for standard appeals.

2. Once an initial fax is sent out, the provider will have at least seven (7) calendar days to respond

with a completed prior authorization (PA) form. If the provider fails to complete a PA form, then the

request may be denied due to insufficient information within fifteen (15) total calendar days from the

initiation of the prior authorization.

Expedited timeframe coverage determinations (including medical necessities, plan benefit reviews, appeals and reconsiderations). 1. Expedited appeals are completed with verbal notification of determination within seventy-two (72) hours of the request, followed by a written confirmation of the notification within three (3) calendar days to both the member and the prescriber.

GENERAL COVERAGE FOR PLAN SPONSORS

A. Inclusions – Drug Product(s) and/or Service(s) must meet the following criteria:

1. Have been prescribed by a licensed Prescriber

2. Be a Drug Product or device approved by the Food and Drug Administration (FDA)

3. Be a designated Federal Legend Drug Product


Page 20 of 27

4. Not be excluded from coverage under the Exclusions below

B. Exclusions – The following products are generally not covered under a Covered Person’s Benefit Plan, but may vary by Plan Sponsor:

1. Disposable and Durable Medical Supplies (DME), non-insulin products

2. Applicators or devices

3. Products used solely for cosmetic purposes (i.e. Rogaine and Propecia)

4. Anorexiants

5. Drug Efficacy Study Implementation (DESI drugs)

6. Agents used for diagnostic purposes

7. Experimental or investigational drugs (Drug Products & Services without FDA approved indication)

8. Over the counter (OTC) products other than insulin, syringes, and those deemed appropriate under a Prescription/Medical Benefit Plan

9. Re-packagers outside of CMS accepted Programs and procedures

10. Serum/Allergens and Toxoids, where applicable

11. Multi-Vitamins (other than prenatal or multi-vitamins with fluoride)

12. Replacement prescriptions resulting from loss, theft, or breakage

13. Any compounded pharmaceutical service that does not contain an ingredient that requires a prescription (legend Drug Product)

FRAUD, WASTE, AND ABUSE (“FWA”) PROGRAM

Healthcare fraud, waste, and abuse (FWA) is a very serious topic and potential offense. FWA is defined as the following and may not be interpreted by any other meaning other than the definitions below. Fraud: A person who knowingly and willfully executes, or attempts to execute, a scheme or artifice to (i) defraud any health care benefit program to obtain, by false or fraudulent pretenses, representations, or promises, health care payments under which no entitlement exists; (ii) knowingly soliciting, receiving, offering, and/or paying remuneration to induce or reward referrals for services reimbursed by any health care benefit program; (iii) making prohibited referrals for certain health services to any health care benefit program; (iv) billing any health care benefit program for services not rendered; (v) falsifying records to show delivery of services not rendered; (vi) paying for referrals for monetary gain; (vii) billing a higher level of service than what was provided (i.e.; higher compound level of effort or delivery services not provided); (viii) providing services without proper licensure. Some examples of fraud include, but not limited to; altering a physician’s prescription, submitting bills/claims to multiple payers for the same prescription dispensing Generic Drug Products but billing for a Brand Drug Product, billing a different NDC than dispensed, submitting an invalid DEA or NPI to receive a paid claim, splitting prescriptions to receive an additional dispensing fee, pill shorting a Covered Person or filling prescriptions not medically necessary. Waste: Is considered misuse or overutilization of any service(s) rendered that may, directly or indirectly, result in unnecessary costs to any health care benefit program.


Page 21 of 27

Abuse: A practice that, either directly or indirectly, results in unnecessary costs to any health care benefit program, or any practice inconsistent of services which are not medical necessary. Abuse includes; billing unnecessary or not medically necessary services, charging or billing for excessively for services and/or supplies, misuse of NDCs on claims to obtain higher reimbursement from any health care benefit program. Federal laws governing FWA include:

False Claims Act (FCA)

Anti-Kickback Statute (AKS)

Physician Self-Referral Law (Stark Law)

Social Security Act

United States Criminal Code, specifically, 18 U.S. § Code 1347. Health Care Fraud ProCare monitors its Pharmacy Network regularly for compliance and risk (please refer to the Audits section for further detail). Network Pharmacies are required to report any potential or suspected FWA to ProCare and as required by law. Pharmacies must cooperate with and assist in aiding state and/or federal agencies with investigation(s) by providing any documentation requested and access to premises and records upon request. ProCare investigates all claims of FWA activity reported by any of its contracted pharmacies, physicians, vendors, associates, contractors, Covered Persons, and/or other business entities capable of potential FWA.

To report a FWA-related incident, please call the Pharmacy Help Desk 800-699-3542

The Help Desk is available twenty-four (24) hours a day, seven (7) days a week, three hundred, sixty-five (365) days a year.

PHARMACY CLAIM AUDITS

All Claims submitted are subject to audit. Pharmacy agrees to permit either an authorized ProCare representative or an independent third party auditor designated and approved by ProCare or Plan Sponsor, access to its books, records, logs, and facilities, as well as, access to scan and photograph for the sole purpose of conducting an audit to ensure compliance of Pharmacy in dispensing Drug Products and/or Services to Covered Persons within the terms of the Agreement. Pharmacy agrees audits may be completed during normal business hours via phone call, desktop audit or on-site visit, in accordance with federal, state and/or local law. Compound Claims are subject to audit review and may require full disclosure of compound recipe upon request. Pharmacy agrees to provide a copy of the compound recipe worksheet identifying ingredients used in the compounded drug, when requested. Institutional Packaging NDC numbers are not covered. Pharmacy shall maintain proper prescription and financial records, including, but not limited to; books, records, signature logs, patient information, hardcopies of prescriptions, Physician information, wholesaler or distributor purchasing invoices, policies and procedures, and any additional information as required by local, state, or federal law, for a minimum of seven (7) years, or as required by applicable law. ProCare reserves the right to audit Claims during the term of the Agreement and for two (2) years following termination of the Pharmacy or Agreement, or longer, only if part of a legal case, or in accordance with state or local law.


Page 22 of 27

ProCare may share audit findings with Plan Sponsors, governmental entities, and/or an audit agency acting on behalf of ProCare, as required. If Pharmacy belongs to a third party affiliation (PSAO), ProCare, at its own discretion, may notify PSAO of audit findings. Pharmacy shall cooperate with either audits conducted by ProCare, or with an agency acting on behalf of ProCare. Pharmacy’s failure to cooperate during an audit will be considered a breach of the Agreement and Pharmacy shall be subject to immediate suspension and/or termination of Network participation. ProCare may offset audit recoupment amounts and/or penalties charged through future payment cycles or via invoicing, at ProCare’s sole discretion.

A. On-Site Audits ProCare may conduct an audit provided it is reasonable in scope, and provided that ProCare has notified Pharmacy in writing at least fourteen (14) days prior to the audit, or in accordance with state law. Pharmacy agrees not to refuse a prescheduled on-site audit at the time of auditor arrival. Pharmacy agrees to provide a work area for the auditor, to be adequately staffed to assist in, answer questions and retrieve information during the audit. Auditors must be given full access to any records, files, logs, copies, invoices and any documentation pertaining to Claims transactions submitted to ProCare. Auditor reserves the right to request copies or take digital images during audit. Failure to assist in audit will be determined a denial of access and a breach of the Agreement and Network participation shall be terminated immediately. Please see the Audit Guide posted to ProCare’s Pharmacy Portal for further information on ProCare’s audit process (https://pharmacy.procarerx.com/networkdocs/audit-guide).

B. Desktop Audits

Pharmacy shall provide records or copies of records requested by ProCare, or its designated auditor, within ten (10) days from the date of notification of the request for such records, or in accordance with state law. In instances where a quantity differs between the actual prescription written by the Physician and the actual amount given to the Covered Person, full detail of the reason for the action and variance must be documented. A hard copy prescription must be kept on file for every prescription and must be accessible upon request, as required by law. For prescriptions labeled “As Directed,” only the prescription written by the actual Physician will be accepted as documentation for an appeal consideration. Please see the Audit Guide posted to ProCare’s Pharmacy Portal for further information on ProCare’s audit process (https://pharmacy.procarerx.com/networkdocs/audit-guide).


Page 23 of 27

C. Investigational Audits Investigational audits are audits performed by ProCare and may include, but not limited to; credentialing documentation, prescription records, signature logs, electronic signature logs and/or Claims. In the event ProCare requests records pertaining to an investigational audit, Pharmacy must agree to comply with the request for documentation immediately. Investigational audits are small in size and considered an inspection of the Pharmacy’s documentation requested. These audits are necessary when initiated by a Plan Sponsor and/or ProCare. D. Network Recovery Program

Pharmacy agrees that ProCare and/or Plan Sponsor shall have the right to reclaim any money, either full or partial, previously paid to Pharmacy for Drug Products and/or Services found incorrectly billed/paid, or not to be in compliance within the terms of the Agreement or Pharmacy practice in accordance with state or federal law. ProCare shall provide reports in writing for any or all services stating exact non-compliant details for each Drug Product or service for which recovery has been determined.

Please see the Audit Guide posted to ProCare’s Pharmacy Portal for further information on ProCare’s audit process (https://pharmacy.procarerx.com/networkdocs/audit-guide).

CONFIDENTIALITY

Pharmacy shall comply with all laws applicable pertaining to confidentiality, use, disclosure and maintenance of Covered Person’s protected health information (PHI). Except as required by law, Pharmacy, on behalf of itself and its employees, contractors and other representatives, agree to treat all PHI, agreements, addenda, exhibits, and manuals as confidential and proprietary, and to take reasonable precautions and care to prevent unauthorized use and/or disclosure of the terms of the agreement, as well as any other information relating to ProCare’s business operations/services in which ProCare considers proprietary information to include, but not limited to, Pharmacy Agreements, MAC listings, reimbursement, pricing, Programs, services, business practices, software, processes, applications, systems, technology, files, exhibits, publications, protocols, information pertaining to Clients, Benefit Plans and Formularies. All proprietary Information remains the exclusive property of ProCare and Pharmacy agrees not to discuss or disclose any proprietary information. In addition, Pharmacy agrees reimbursement terms are considered proprietary and are not to be discussed with any Client, Plan Sponsor, Covered Person, Covered Person’s Representing Agent, other pharmacy (participating or non-participating), without prior written authorization from ProCare. Pharmacy acknowledges and agrees any discussions pertaining to the reimbursement of Drug Products and Services with any Client, Plan Sponsor, Covered Person, Covered Person’s Representing Agent, other pharmacy (participating or non-participating) is considered a breach of the Agreement and could result in immediate termination from ProCare’s Networks. For affiliated Pharmacies (Pharmacies contracted with a chain, PSAO or a third party contracting entity), all reimbursement inquires and communications are required to be directed through the Pharmacy’s affiliation, unless otherwise specified by ProCare. Affiliated Pharmacies are not permitted to discuss


Page 24 of 27

reimbursement with any Client, Plan Sponsor, Plan Sponsor’s staff, Covered Person, or Covered Person’s responsible party. Any discussion pertaining to the Pharmacy’s reimbursement with any party other than Pharmacy’s chain affiliation, or in some cases, ProCare directly, is considered a breach of the chain affiliation Agreement with ProCare, and could result in immediate termination from ProCare’s Networks. The chain affiliated Pharmacy is subject to all current terms and conditions of the Agreement between the respective chain and ProCare through the allowance of such sub-contracting during the time the Pharmacy is active with the respective chain affiliation, as reported by NCPDP.

MISCELLANEOUS Additional information regarding ProCare’s Network, including forms, communications, notices, and updates, may be obtained by visiting https://pharmacy.procarerx.com. It is the Pharmacy’s responsibility to visit the webpage periodically for updates and changes to Manual. This Manual is updated periodically, at the sole discretion of ProCare. ProCare shall post the most current version of the Manual on the Pharmacy Portal. The Manual applies to all lines of business and is considered an extension on the Pharmacy’s Agreement. It is the Pharmacy’s responsibility to ensure they are using the most current version of the Manual when referencing. Pharmacies who leave their affiliated chain entity will not be considered contracted/participating after the date of termination with the chain entity, as reported by NCPDP. The pharmacy will need to request a direct contract via [email protected] to obtain the applicable contracting documents to apply for Participating status within ProCare’s Networks. Agreement effective dates will not be retro-activated unless authorized in writing by Plan Sponsor and/or ProCare. ProCare updates its files regularly through monthly data feeds from NCPDP, or other nationally recognized provider data vendors, as determined by ProCare. Such data includes, but is not limited to, Pharmacy NCPDP number, NPI number, Pharmacy chain affiliation, demographics, licenses, Pharmacy status, Dispenser Types, and chain termination dates, if applicable. It is the Pharmacy’s responsibility to contact NCPDP and update any information and/or changes to ensure the integrity of ProCare’s files and database. ProCare will not make changes to any Pharmacy record unless NCPDP reflects such change(s). If Pharmacy refuses to update NCPDP, Pharmacy will be responsible for any errors in data provided to Covered Persons, Pharmacy payments and any reimbursement-related issues. ProCare reserves the right to recoup any monies due on behalf of Plan Sponsors should Pharmacy fail to maintain NCPDP with the correct data. ProCare is committed to quality surrounding the Network and may at times engage the Pharmacy in Quality Improvement initiatives, activities or surveys through communications via direct outreach or via the ProCare Provider Portal. Pharmacy may submit suggestions directly to ProCare via email, telephone or fax. Pharmacy understands participation in a Network does not grant access into all Networks. ProCare and/or Plan Sponsor reserve the right to limit participation in a Network, at its sole discretion. Furthermore, Pharmacy agrees to participate all in applicable Networks and shall not be allowed to opt-out without written consent from ProCare. ProCare may immediately terminate or suspend the Agreement or any applicable Amendment, Addendum or Exhibit pursuant to business needs, Plan Sponsor request or any of the following reasons, including but not limited to:


Page 25 of 27

Failure to meet/maintain credentialing standards, failure to retain liability insurance (i.e. lapse, cancellation or suspension), loss of state licensure, excluded from federal programs (OIG)

Fraudulent Claim submission activity detected

ProCare has reason to suspect Pharmacy is/has engaged in fraudulent practices of federal and state law

Covered Person(s) are refused Services as required by the Agreement

Any automated reversal process(es)

Rejecting Covered Persons at the point of sale for a non-clinical reason, or steering to other coverage to improve compensation, including discount cards

Breach of any term set forth in the Agreement and/or Manual

Refusing to provide Services to a Covered Person based on reimbursement

Covered Person is charged more than the Co-Payment

Pharmacy agrees not to advise, counsel or solicit Covered Persons with Plan Sponsors utilizing ProCare for any reason, including, but not limited to compensation. Pharmacy agrees not to advise, counsel or solicit Plan Sponsor to terminate its relationship with ProCare for any reason. Pharmacy agrees such behavior is strictly prohibited and shall be grounds for immediate termination under the Agreement.

ProCare’s Pharmacy Manual is considered confidential and proprietary. Pharmacy agrees to not copy, distribute, or share information included in this Manual, except, as required for business or contract purposes only.

Continued on next page.


Page 26 of 27

Connecticut Supplement: Pursuant to CGS §38-a-477dd, ProCare’s Pharmacy Provider Agreement shall not contain any provision prohibiting or penalizing, including, but not limited to, through increased utilization review, reduced payments or other financial disincentives, disclosure of any information to a covered person, as defined in Section 38a-591a , concerning: (1) the cost of a covered benefit, including, but not limited to, the cash price of a covered benefit; or (2) the availability and cost of any health care service or product that is therapeutically equivalent to a covered benefit, including, but not limited to, the cash price of any such health care service or product. Pursuant to CGS § 38a-477f, all ProCare agreements concerning data or analytical services to evaluate and manage health care services shall provide for the disclosure of (1) billed or allowed amounts, reimbursement rates or out-of-pocket costs, or (2) any data to the all-payer claims database program established under section 19a-755a. Maryland Supplement:

Maryland Code, Insurance § 15-1628: At the time of entering into a contract with a pharmacy and at least 30 working days before any contract change, ProCare shall disclose to the pharmacy or pharmacist: (1) the applicable terms, conditions, and reimbursement rates; (2) the process and procedures for verifying pharmacy benefits and beneficiary eligibility; (3) the dispute resolution and audit appeals process; and (4) the process and procedures for verifying the prescription drugs included on the formularies used by ProCare. Maryland Code, Insurance § 15-1005(e)(1): ProCare shall permit a provider a minimum of 180 days from the date a covered service is rendered to submit a claim for reimbursement for the service. Maryland Code, Insurance § 15-1628:

If ProCare retroactively denies reimbursement to a health care provider, it shall only retroactively deny reimbursement for services subject to coordination of benefits with another carrier, the Maryland Medical Assistance Program, or the Medicare Program during the 18-month period after the date that the carrier paid the health care provider; and in the event of a retroactive denial ProCare shall only retroactively deny reimbursement during the 6-month period after the date that ProCare paid the health care provider. ProCare shall provide the health care provider with a written statement specifying the basis for the retroactive denial. If the retroactive denial of reimbursement results from coordination of benefits, the written statement shall provide the name and address of the entity acknowledging responsibility for payment of the denied claim. Maryland Code, Insurance § 15-1008(c):

(1) If a carrier retroactively denies reimbursement to a health care provider, the carrier:


Page 27 of 27

(i) may only retroactively deny reimbursement for services subject to coordination of benefits with another carrier, the Maryland Medical Assistance Program, or the Medicare Program during the 18-month period after the date that the carrier paid the health care provider; and (ii) except as provided in item (i) of this paragraph, may only retroactively deny reimbursement during the 6-month period after the date that the carrier paid the health care provider. (2) (i) A carrier that retroactively denies reimbursement to a health care provider under paragraph (1) of this subsection shall provide the health care provider with a written statement specifying the basis for the retroactive denial. (ii) If the retroactive denial of reimbursement results from coordination of benefits, the written statement shall provide the name and address of the entity acknowledging responsibility for payment of the denied claim.

ProCare shall not directly or indirectly charge a contracted pharmacy in the State of Maryland or hold such pharmacy responsible for a fee or performance-based reimbursement related to the adjudication or an incentive that is not specifically enumerated by ProCare or a Member at the time of claims processing or reported on the initial remittance advice of an adjudicated claim.

Documents

Pharmacy Admin Manual - mc-rx.com · This Pharmacy Manual (“Manual”) is intended to serve as a guide with submitting claimsto assist to ProCare, as well as providing general terms,